Robot-Assisted Upper Pole Hemi-nephroureterectomy for Vaginal Ectopic Ureter

A duplex kidney with vaginal ectopic ureter insertion is a rare congenital anomaly frequently presenting as refractory urinary incontinence in females and often misdiagnosed as neurogenic bladder or vesicovaginal fistula. The authors describe the case of a 41-year-old female with progressive relapsing-remitting multiple sclerosis (EDSS 6.5), wheelchair dependent, bilateral hip arthroplasties, persistent vaginal leakage, recurrent multidrug-resistant Escherichia coli urinary tract infections, and initial misattribution to neurogenic bladder leading to intermittent self-catheterization. Multimodal imaging-contrast-enhanced CT urography, retrograde pyelography, and MAG3 renal scintigraphy-revealed a right-sided duplex kidney with a non-functioning, hydronephrotic upper pole moiety (0% differential function) and a tortuous megaureter (30 mm diameter) ectopically draining into the vaginal vault. Following percutaneous nephrostomy for decompression and antibiotic treatment for infection control, robotic-assisted upper pole heminephroureterectomy was performed. Indocyanine green fluorescence guidance enabled precise upper pole resection. The ectopic ureter was traced and excised distally. The procedure lasted 90 min with 50 mL blood loss and no intraoperative complications. The postoperative course was also uneventful. The 12-month follow-up demonstrated complete resolution of incontinence with high patient satisfaction. This case illustrates the diagnostic challenges of ectopic ureters in adults with neurological impairment and demonstrates the feasibility and favorable outcome of robotic surgery for complex congenital urogenital anomalies in high-risk patients.